Obstructive uropathies in children at UNTH Enugu

1. Obstructive uropathies in children at UNTH Enugu DR. H.U. OKAFOR CONSULTANT PAEDIATRICIAN UNTH ENUGU

2. OUTLINE • INTRODUCTION • STUDY OBJECTIVES • METHODOLOGY • FINDINGS • DISCUSSION

3. Introduction • Posterior Urethral valves has been severally reported as the commonest cause of obstructive uropathy in Nigerian children. (Anochie,2004;OkoroB.A et al,1999). • At the UNTH Enugu ,a total of 51 cases of obstructive uropathy in children were seen between 2008 -2011. & Of these 41 (80.4%) were cases of PUV • Reports from developing countries indicate that diagnostic and therapeutic difficulties in addition to patient factors contribute to the high morbidity and mortality rates in these cases of PUV. • In order to optimize outcome, we felt there is need to identify these factors. • We set out to evaluate the determinants of outcome in patients seen in our centre as it is a major referral centre in SE Nigeria.

4. Study objectives • To evaluate profile of PUV • To ascertain determinants of outcome • To identify challenges of management

5. Methodology • A prospective cohort study whereby all cases with a diagnosis of PUV from January 2008 were recruited and followed up. • Data collected included age, mode of presentation ,anthropometric measurements, results of blood &radiological investigations. • Treatment given & post intervention results, challenges encountered and outcome were also documented. • Radiological investigations were repeated 3 months post intervention. • Renal function tests were done monthly.

6. Results • 31 children were seen between Jan.2008 –Dec 2009. • Median age at presentation was 2.5yrs with a range of 2weeks-15years. • 22 (71%)children had prenatal ultrasonograhy;5 had oligohydramnios, and only 2 were diagnosed prenatally. • 18 had onset of symptoms before 1mth while 13 became symptomatic about 2years.

7. Results

8. Clinical Features contd.

9. Treatment • Prior to treatment,4pts required dialysis • 8pts required upper tract diversion in form of cutaneous ureterostomy. • Catheter balloon avulsion was done on 28pts • Post avulsion undiversion was done in all 8 cases with cutaneous ureterostomy.

10. outcome • Mean eGFR after 3months was 64.8ml/min/1.73m2+_ 11.6 • In those with ureterostomy mean GFR increased from 31.6ml/min/1.73m2 to 72.9ml/min/1.73m2. • Overall ,18 cases had clinical ,biochemical and radiological improvement. • 9 still had poor renal function • 4 died,2 of which were neonates and the others were 13 and 15 yrs respectively. • Causes of death were acute renal failure and pulmonary hypoplasia in neonates and ESRD in the older patients. • Average duration of follow-up was 12.6months • During this period 8 of the surviving cases with VUR have resolution while 2 are awaiting reflux surgery.

11. Discussion • PUV is the commonest form of obstructive uropathy seen at UNTH Enugu. Pre-natal diagnosis is low probably due to lack of expertise. • Onset of symptoms occur early but presentation to the hospital is usually late due to lack of awareness amongst both health workers and caregivers. • Mortality was significantly affected by bilateral VUR and eGFR. • Infections and renal failure apparently contribute immensely to morbidity and mortality. Poor access to adequate RRT is a major problem.

12. Conclusion • Most of our PUV cases present late. • Management is challenged by poverty, lack of facilities for RRT etc. • Overall outcome is adversely affected by extremes of age, low eGFR at presentation, associated bilateral VUR.

13. Recommendations • To create awwareness amongst mothers and primary health workers • To emphasize the need to observe urinary stream in male infants • To encourage early refferals

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